A 42-year-old woman with AIDS and pulmonary tuberculosis presents to Mulago Hospital in Kampala, Uganda, complaining of weakness.

History

The patient presents complaining of several weeks of generalized weakness and fatigue. She notes poor appetite and significant weight loss (she is not able to quantify, but her clothes no longer fit) during the past 2 months. She also reports intermittent subjective fevers. She treated herself for malaria a few weeks ago but did not have any improvement in her symptoms. She is having frequent, loose, watery stools and very infrequent urination. She also complains of numbness and tingling in her feet. She has been too weak to get out of bed and she was carried to the hospital by family members.

Pulmonary tuberculosis: diagnosed on acid-fast bacilli (AFB) staining of sputum smears; currently in the continuation phase of therapy

History of oral candidiasis

Medications

Zidovudine, lamivudine, nevirapine

Ethambutol and isoniazid (completed 4 months of 8-month regimen)

Trimethoprim-sulfamethoxazole

Multivitamin, ferrous sulfate, folic acid, vitamin B6

Social History

The patient's daughter and husband died of AIDS. She is the primary caretaker of her 3 grandchildren, who share her 2-room mud house that has no electricity. She completed primary school education and used to earn a living by selling secondhand clothing, but has not been able to work for the past year because of illness. She uses a device to purify her water supply, which she obtains from a nearby well. She denies smoking or alcohol consumption.

Physical Exam

General: pleasant, cachectic woman lying quietly on the ground on bedding that her family provided

Based on the patient's history, physical examination, and available studies, a diagnosis of malnutrition was made. According to the World Health Organization (WHO), severe malnutrition in adults is defined by the presence of 3 criteria: edema, weight-for-height index below 70% or MUAC <160 mm, and BMI <16.

Treatment

The patient received albendazole for empiric treatment of intestinal worms, amoxicillin for empiric treatment of bacterial infections, and oral rehydration therapy and 3-phase nutritional supplementation according to WHO guidelines. Two weeks later, at the time of discharge, her weight had increased to 38 kg and she was able to ambulate without assistance.

The treating team felt that other diagnoses had been excluded, based on the patient's history, the physical examination, and results of available studies. Because the patient responded to the rehydration and refeeding therapy, and did not require other treatments in order to improve, her admission was deemed secondary to malnutrition.

Follow-Up

The patient was seen 2 weeks after she was discharged from the hospital at a home visit. The patient continued to note poor appetite. She denied experiencing fever, dysphagia, nausea, vomiting, abdominal pain, or diarrhea. A community health worker confirmed her report of 100% compliance with her tuberculosis medications and ART.

Upon further questioning, it became apparent that the patient had poor access to food despite her enrollment in the United Nations' World Food Program upon starting ART 2 months earlier. As a client of the Reach Out clinic in Kampala, the patient receives daily food supplementation through the U.N. program. The food supplementation for people receiving ART and tuberculosis therapy amounts to 1,048 kcal per day. This includes 150 g of cereal/grains, 40 g of beans, and 100 g of a corn/soya blend fortified with micronutrients. Additionally, a clinician, accompanied by a community health worker, makes weekly home visits to check on the patient's weight. In spite of food supplementation, the patient has made minimal improvement in her weight, probably because she has been sharing her supplement with her extended family members (immediate family members are provided supplementation).